Epidemiologia delle Infezioni nelle Organizzazioni Sanitarie Corso precongressuale: Le Infezioni Ospedaliere Epidemiologia delle Infezioni nelle Organizzazioni Sanitarie Nicola Petrosillo U.O.C. Infezioni Sistemiche e dell’Immunodepresso Istituto Nazionale per le Malattie Infettive “Lazzaro Spallanzani”, IRCCS-Roma

Infezioni correlate a organizzazioni assistenziali (ICOS) Infezioni acquisite durante il ricovero in ospedale Infezioni acquisite in day hospital, day surgery Infezioni acquisite in ambulatorio Infezioni in day care

Klevens RM et al. Public Health Reports 2007; 122: 160-6

Klevens RM et al. Public Health Reports 2007; 122: 160-6

Klevens RM et al. Public Health Reports 2007; 122: 160-6

Device-specific incidence rates/utilization ratio U. ratio X 1000 days 1 UTI BSI 5 0,5 VAP CVC Urin cath Ventilator Edwards JR et al. Am J Infect Control 2007;35:290-301.

Main prevalence surveys on hospital infections (HI) in Italy Author/year Setting #pts % prev. Moro (1983) 130 Italian hospitals 34,577 6.8 Tuscany(87) 26 hospitals 5,564 5.1 Moro (1984) 15 hospitals in Rome 5,695 5.5 Castelnuovo (98) 36 wards of a hospital 623 5.8 Mancarella (98) 3 hospitals in Chioggia 435 Lazzeri (98) 6 hospitals in Florence 684 7.2 Marena (98) 1 teaching hosp in Pavia 3,073 6.4 Pavia (1999) 4 hospitals in Catanzaro 888 1.7 Privitera (88) 259 Italian surgical wards 11,343 5.0 Ippolito G, Nicastri E, Martini L, Petrosillo N. Infection 2003;31(S2):4-9

Main incidence studies on hospital infections (HI) in Italy Author (year) Setting # patients % incidence Ippolito (1985) 71 Italian Intensive care units 6,589 29.5 Ortona (1985) One teaching hospital 10,385 6.7 Greco (1987-89) 20 surgical wards 7,641 13,6 Scolfaro (1994) One infectious pediatric unit 229 7.8 Pallavicini (1995-98) One ICU in a teaching hospital 3,679 12.6 Scotton (1996-97) One neurosurgical ICU 562 14.8 Petrosillo (1997-98) 19 Infectious Diseases Units 4,330 HIV+ 6.3 Valera (1998-99) One pediatric cardiac surgery unit 104 30.8 Romagna Region (2001) Hospitals in Emilia Romagna Regione 6,158 4.7 Di Palo (1980-82) One surgical unit 991 3.8 SSI Mosconi (1983-84) 23 ICUs 1,475 15.0 VAP 71 Italian ICUs 6,598 14.1 VAP Moro (1991) 52 Italian ICUs 672 9.4 VAP 7 hospitals 607 9.3 CR-BSI Alvarenz (1993-96) One vascular surgical unit 806 1.8 SSI Brusaferro (1996) 12 hospitals in Friuli Region 1,625 21.5 UTI Petrosillo (1998-99) 17 Infectious Diseases units 1,379 HIV+ 4.7 nosocomial BSI Ippolito G, Nicastri E, Martini L, Petrosillo N. Infection 2003;31(S2):4-9

SSI – a European perspective of incidence and economic burden Costs of additional hospitalization days associated with SSI Source Country Cost per day Cost for mean of 9.8 days Netten & Curtis UK 409 4,008 Oostrenbrink Netherlands 230 2,254 DKG Germany 317 3,107 Pena Spain 170 1,666 PMSI France 412 4,038 Orsi Italy 413 4,047 Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. 2004

ICOS DIMENSIONI DEL PROBLEMA colpiscono circa il 5-10% dei pazienti ricoverati rappresentano circa il 50% delle complicanze ospedaliere casi annui: 450.000-700.000 decessi annui: 4.500-7.500 costo annuo:1 miliardo di euro

ICOS INTERVENTI POSSIBILI quota prevenibile: 30-40% casi evitabili: 135.000-210.000 decessi evitabili: 1.350-2.100 costo evitabile: 300 milioni di euro

Quanto ci si lava le mani in Ospedale? Il valore medio è solo del 40% Adesione al lavaggio delle mani da parte degli operatori sanitari Una valutazione di 34 studi pubblicati sulla adesione al lavaggio delle mani tra gli operatori sanitari ha riscontrato che questa adesione varia dal 5% al 81% Il valore medio è solo del 40% Media Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002, Vol.51

Pittet D et al. Int J Infect Dis 2006; 10: 419-24

Core element of hand transmission. Contestualization of the risk Sax H et al. J Hosp Infect 2007; 67:9-21

Sax H et al. J Hosp Infect 2007; 67:9-21

Sax H et al. J Hosp Infect 2007; 67:9-21

Healthcare-associated infections: main issues Pathogenicity of microorganisms Risk factors Immunosuppression Cross contamination Antibiotic pressure and resistance Emerging organisms Relevance of clones in HAI epidemics Strategies -search and destroy -developing a culture of safety - WHO campaign Social aspects of HAI - antibiotic use - medico-economic aspects - non-traditional forces to change HAI prevention

Infezioni post-operatorie in Italia Petrosillo N et al BMC Infect Dis 2008; 7;8:34. 4665 interventi in 48 chirurgie 316 infezioni (6,8 per 100 interventi) 0,8% 0,5% 5,4% Circa la metà dopo la dimissione

Klevens RM et al. JAMA 2007; 298:1763-71

The risk of infection in LTCFs

4 LTCFs in NE Italy 859 pts. (79.3 ± 11 years)

The risk of infection in LTCFs In nursing homes, the prevalence of antibiotic resistance is extremely high Red columns: frequency higher than the 90° percentile reported by NNIS in medical ICUs Gould CV et al ICHE 2006; 27: 920-25 (45 LTCFs, 2002-2003)

Hematogenous complications in 42/342 (13%) pts with S. aureus CR-BSI Fowler VG Jr et al. Clin Infect Dis 2005;40:695-703

Staphylococcus aureus Endocarditis. A Consequence of Medical Progress Prospective observational cohort study set in 39 medical centers in 16 countries. 1779 patients with definite IE as defined by Duke criteria (International Collaboration on Endocarditis-Prospective Cohort Study) from June 2000 to December 2003. 558 S.Aureus IE Fowler VG, Jr et al. JAMA 2005; 293:3012-21

Ventricular Assist Device Ventricular assist device-related infections occur in 18–59% of patients after implantation Infection can involve any aspect of the device: the surgical site the driveline the device pocket the pump itself (More than half infections include multiple sites) Complications: bloodstream infection Relapsing bacteraemia Sepsis Device-associated endocarditis Rarely: mediastinitis, peritonitis, pseudoaneursysm Lancet Infect Dis 2006

Ventricular Assist Device Timing of ventricular assist device-related infections: Most infections occur between 2 weeks and 2 months of implantation Only 5–10% of patients developed infections beyond 3 months Microbiology: Staphylococcus aureus and epidemidis (24-56%) Enterococci Gram-negative bacilli (eg, Pseudomonas aeruginosa, Enterobacter, Klebsiella) Fungi (Candida) Outcome: Serious device-related infection, such as endocarditis, is associated with up to 50% mortality Device infection is significantly associated with decreased survival after transplantation Lancet Infect Dis 2006

24% of colonized patients developed S 24% of colonized patients developed S. aureus infection versus 2% of noncolonized patients (p<0.01) Keene A et al. Infect Control Hosp Epidemiol 2005;26:622-28

Pan A et al. Infect Control Hosp Epidemiol 2005;26:127-133

J Hosp Infect. 2007;67:308-15

Infection in Solid-Organ Transplant Recipients Fishman JA. N Engl J Med 2007; 357: 2601-14

Nusair A et al. Infect Control Hosp Epidemiol 2008; 29: 424-29

Nusair A et al. Infect Control Hosp Epidemiol 2008; 29: 424-29

Transplantation Proceedings 2008; 40, 1986–1988

Mattner F et al. J Heart Lung Transplant 2007; 26: 241-9

Mattner F et al. J heart Lung Transplant 2007; 26: 241-9

From 1988 to 2004, 51 patients underwent SPKT systemic 13 pulmonary 13 urinary tract 15 intestinal 8 wound 23 (45%) Michalak G et al. Transplantation Proceedings 2005; 37, 3560–3563

SSI and transplant Patients who develop SSI are twice as likely to die, 60% more likely to be in the intensive care unit, and 5 times more likely to be readmitted to the hospital after discharge. This manifested also in longer hospital stays and higher hospitalization costs. Kirkland KB et al.. Inf Control Hosp Epidemiol 1999;20:725-730

Clostridium difficile associated colitis (CDAD) and transplant The reported incidence of CDAD varies from 3.5% in adult kidney recipients to 31% in lung transplants. This variability may be due to differences in the type of organ transplantation, diagnostic methods, Immunosuppressive regimen, time after transplantation, follow-up period - and other population characteristics.

The annual incidence of CDC in lung transplant recipients was 2.1%. Between November 1990 and November 2005, 202 consecutive patients underwent 208 lung transplantation procedures. Fifteen of 208 lung recipients developed 23 episodes of CDC with a median follow-up period of 2.7 years (range, 0-13.6) The annual incidence of CDC in lung transplant recipients was 2.1%. All patients with confirmed disease had at least 1 of the following 3 risk factors: recent antibiotic use, recent hospitalization, or augmentation of steroid dosage. Gunderson CC et al. Transpl Infect Dis 2008: 10: 245–251

Gunderson CC et al. Transpl Infect Dis 2008: 10: 245–251